Treatment of edentulous patients using implant supported ...
Reviews: Dentistry Leo Pharma - Merit Award WinnerTreatment of edentulous patients using implant supportedmandibular overdentures improves quality of lifeSarah Enright, 5th year Dentistry CLINICAL POINTS • The standard of care for the edentulous patient has been the provision of a complete denture, however a large proportion of patients have problems with the retention and stability of the mandibular complete denture • Pre-prosthetic surgery(PPS) has a history of poor prognosis • The McGill Consensus states that the two implant mandibular overdenture should be considered as a first choice standard of care • Compared to complete dentures and PPS, improvements have been demonstrated in areas such as patient satisfaction, nutrition, and quality-of-life • Quality-of-life is a useful method to demonstrate treatment success, however, the use of individualized quality-of-life measures may prove more relevant in the futureINTRODUCTION measured by socio-dental indicators. Locker defined these indicators as; measures of the extent to whichAn overdenture (OD) is defined as a prosthesis that dental and oral disorders disrupt normal social rolecovers and is partially supported by natural teeth, tooth functioning and bring about major changes in behaviourroots, and/or dental implants1. such as an inability to work or attend school, or undertake parental or household duties7. Therefore QOL affectsTooth loss is a serious life event2. According to the WHO denture wearers with regard to patient satisfaction,criteria edentulism is a form of physical impairment,3 the nutrition and psycho-social aspects of life. QOL is,loss of all teeth causes a disability for most people who however, adversely affected by tooth loss.wear conventional dentures (CD) as they may havedifficulty in performing two essential tasks; eating and The sequelae of tooth lossspeaking. The effects of tooth loss are two-fold which may affect the patient psychologically and clinically.Quality of life (QOL) is defined as an individualsperception of their position in life, in the context of the Psychologically, edentulism has been quoted as havingculture and value systems in which they live, and in characteristics of a chronic illness as it is incurable andrelation to their goals, expectations, standards and functionally and physiologically disruptive8. Reduced selfconcerns4. The impact of health and disease on QOL is confidence, taboo and the feeling of premature ageingknown as health-related QOL. Another dimension of QOL have also been reported by patients8.is Oral health-related QOL. This is defined as anindividuals assessment of how the following affect his or Clinically the effects of tooth loss are important. Alveolarher well-being: functional factors, psychological factors, bone resorption could be considered as a pathologicalsocial factors, and experience of pain or discomfort in condition and can pose a prosthodontic dilemma for therelation to orofacial concerns5. restoration of the edentulous mandible. There has been extensive research regarding this aspect and its clinicalQOL is established as an important outcome for sequelae. Tallegren reported that the mean decrease inevaluating the impact of disease and for assessing the anterior mandibular ridge height was 4 times greater thenefficacy of treatments6. QOL in denture wearers is that of the maxilla9. Image 1 & 2: Progression of alveolar bone resorption in the mandible over a 15 year period10 TSMJ Vol 8 2007 65
Reviews: DentistryCrum and Rooney found that retaining mandibular A symposium was held at McGill University where acanines and providing an OD resulted in 0.6mm of panel of experts concluded that a 2 implant overdenturealveolar bone loss11. Provision of a CD resulted in 5.2mm (OVD) should be considered as a first choice standard ofof bone loss12. Therefore preserving teeth and providing care for the edentulous mandible17.an OD can preserve bone not only local to the teeth, butalso in adjacent areas. The ISMOVD has been investigated since 1987, with Van Steenberghe18 being one of the first authors to proposeAlveolar bone loss can be reduced by the provision of the placement of 2 implants in the mandible to support animplants; studies have shown that implant-supported OVD. Within 52 months, a 98% success rate wasmandibular overdentures (ISMOVDs) can preserve bone achieved18. Albrektsson et al. have argued that a state ofheight in areas where the implants are located 12. almost, "restitution ad integrum," can be achieved withMericske-Stern also concluded that there is a higher dental implants19.probability of success in the mandible when ODs aresupported by implants rather than tooth roots13.Treatment modalities for the edentulous mandibleTreatment modalities for the restoration of the edentulousmandible include: a mandibular CD, pre-prostheticsurgery (PPS) with a mandibular CD, an ISMOVD and animplant-supported fixed bridge.Much of the literature focuses solely on the comparison ofthe ISMOVD with the CD, with or without PPS. Thissection will, therefore, compare and contrast thesetreatments by analysis of current literature and, thus, show Image 4: Patients should be instructed to remove their prosthesis athow the restoration of the edentulous mandible with an night. A soft single-tufted brush is indicated to keep attachments freeISMOVD should be considered as a first choice standard from plaque and calculus22of care. ISMOVDs require frequent maintenance, especially during their first year20. Attard et al. concluded that theThe classic treatment for the edentulous mandible is a cumulative survival rate of the OD was 100%, at 15 years,mandibular CD. However the pattern of bone loss with the longevity of this prosthesis being 10.39+/-5.59associated with the CD can result in the denture-bearing years20. Relines were required every 4-5 years for botharea becoming compromised. Redford demonstrated that the OD and opposing CD20. However, less after-care wasmore then 50% of CD wearers have problems with the associated with surface treatment of the implants and theretention and stability of their mandibular CD14. Whenthe patient experiences poor denture retention and use of Dolder bars21. Patients must be informed thatstability, patient satisfaction, confidence and comfort will regular maintenance will be required. Also, this will givesuffer. the clinician the opportunity to regularly review the patient and detect possible pathology which may otherwise haveThe rate of resorption of the mandibular alveolar bone is adversely affected them.greater than that of the maxilla 9. PPS (ridge QOL-Patient Satisfactionaugmentation or vestibuloplasy) has, therefore, beenadvocated in certain clinical circumstances. There is, It is accepted in the literature that satisfaction in denturehowever, mixed long-term success rates associated with wearers depends upon the ability of the patient to chewPPS; complications and morbidity are also associated15, and speak, and also on the appearance of the16. prosthesis23, 24, 25. Berg et al. found that 66% of patients were dissatisfied with their CDs due to discomfort, sub- optimal retention and fit, and/or pain associated with the lower CD26, 27. Many studies have assessed patient satisfaction with ISMOVDs27-36. Wismeijer et al. carried out a randomized controlled trial (RCT) where patients were provided with ISMOVDs with either ball attachments, an interconnecting bar, or 4 interconnected implants37. Sixteen months after treatment almost all of the patients were satisfied with treatment irrespective of attachment system used37.Image 3: The use of 2 implants in the anterior mandible to support anOVD10 66 TSMJ Vol 8 2007
Reviews: DentistryBoerringter et al. assessed patient satisfaction in a RCT31. QOL-Psychosocial effects of ISMOVDsThis study compared the CD with an ISMOVD. Blomberg stated that teeth do not function just as a part ofSatisfaction was measured with a validated questionnaire the masticatory system; the oral region is also a speechwhich assessed: esthetics, retention, comfort, and and a psycho-sexual centre43. The success of denturefunction of the upper and lower denture. The majority of treatment is not solely based upon functional parameters.the ISMOVD group (85%) had a score of 8 or more (score1=very dissatisfied, score 10=very satisfied)31. Results The effects of denture wearing on social activities haveshowed that the ISMOVD group was more satisfied 1 year been studied by Heydecke et al. who carried out a 2post-treatment. Dissatisfaction in the CD group was due to month follow-up RCT comparing CDs and ISMOVDs44.the poor retention of the lower CD; only 27% were Many studies use scales such as the Oral Health Impactsatisfied post-treatment31. The design of this study shows Profile (OHIP) to measure QOL. Unlike the Soical Impacta high degree of validity, however, a longer follow-up is Questionnaire (SIQ), the OHIP does not take into accountrequired. social or sexual activities. This study concluded that the ISMOVD had a positive effect on social activities 2 monthsThe first prospective RCT with a 10 year follow-up was post-treatment. Conversely, the instability of the CD wascarried out by Raghoeber et al. 37. Patients were shown to adversely affect social activities andrandomized as follows: a) CD (control group); b) PPS with interpersonal relationships. Unease in interpersonala CD; and, c) ISMOVD. Within 1 year, the PPS and relationships was reduced by 32% 2 months post-ISMOVD group experienced better chewing ability than treatment with the ISMOVD44. The SIQ scale showed athe CD group. The PPS group was satisfied in the short- high level of reliability. However a longer follow-up periodterm. The ISMOVD group experienced long-term is still required.satisfaction (10 years.) The effect of the ISMOVD on social activities was alsoFrom the above evidence it can be concluded that patient studied by Melas et al. who carried out a retrospectivesatisfaction is improved with the provision of an ISMOVD cohort study based upon the Oral Impacts on Dailycompared to a CD, with or without PPS. Patients were not Performances (OIDP) sociodental indicator45. The OIDPonly satisfied in the short-term but also at a 10 year recall. measured psycho-social variables such as: smiling, clear speech, emotional status, social contact and, "going out."QOL-Nutrition Results showed that patients with ISMOVDs were moreAs tooth number decreases, mastication is more difficult; satisfied with the comfort of their dentures. Sizablepatients are also more likely to practice forms of food percentages (66%) of CD wearers were dissatisfied withavoidance and dietary restriction. the comfort of their prostheses45. The main limitation of this study was its design. The groups were also notMorais et al. revealed that patients provided with an comparable on the basis of age; however, from previousISMOVD reported an increased ability to bite, eat and literature it seems that there is no relationship betweenchew, without losing their dentures, 6 months post- age and patient satisfaction46. Thus, age is unlikely totreatment38. This group also showed improvements in have confounded the above results.anthropometric data and blood nutrient data. Serumalbumin concentration increased by 1.4g/l (a recognized From the literature, patients restored with ISMOVDsindicator of good general health) 39. Serum B12 experience less discomfort and improved psychosocialconcentrations also increased. These findings, however, function. Studies with longer follow-up periods areshould be supported by a larger RCT with a longer follow- required.up in the future. DISCUSSION & CONCLUSIONSThe process of dietary restriction amongst edentulouspatients has also been studied. Allen and McMillan found The standard treatment of the edentulous patient has, forthat subjects who received ISMOVDs altered their food many years, been a CD. Many CD wearers havechoices, including, "hard to chew foods"40. significant problems in adapting to their mandibular prosthesis. The widespread use and abuse of dentureFrom the literature it can be concluded that the ISMOVD adhesives is a good indication that these prostheses areoffers the patient significant improvements in nutritional inadequate in relation to retention and stability. CDs havestatus. The ISMOVD will not necessarily result in the many disadvantages such as: continual ridge resorptionpatient eating a more balanced diet of their own accord. with fibrous replacement, instability of the CD,Thus, in order to allow patients benefit most from their displacement of the CD, variable levels of acquiredimproved masticatory function, dietary advice should be muscular control, changes in facial support, reducedgiven40, 41, 42. masticatory efficacy and emotional distress from tooth loss47. PPS has also been associated with poor results15, 16. TSMJ Vol 8 2007 67
Reviews: DentistryTreatment of the edentulous mandible with an ISMOVD REFERENCEShas been advocated by Mericske-Stern in elderly patients,who require stabilization of their mandibular CD, and in 1. The Glossary of Prosthodontic terms, edition 6. J Prosthet Dent 1994;patients with congenital or acquired maxillofacial defects 71: 89which require oral rehabilitation48. 2. Bergendal B. The relative importance of tooth loss and denture wearing in Swedish adults. Community dental health1989; 06;103-111 3. The World Health Organization. International classification of functioning, disability and health: ICF. Geneva: World Health Organization, 2001 4. Study Protocol for the World Health Organization project to develop a quality of life assessment instrument (WHOQOL). Quality of life Res 2 1993; 2: 153-159 5. Inglehart MR, Bagramian RA (2002) Oral health related quality of life: an introduction. Inglehart MR, Bagramian RA eds, Quintessence Publishing, Chicago, 1-6 6. Locker D. An Introduction to Behavioral Science and Dentistry. London. Routledge. 1989 7. Locker D. Disability and Disadvantage: The Consequences of Chronic Illness. London. Tavistock Publications, 1983 8. J.Fiske, D.M.Davis, C.Frances, S.Gelbier. The emotional effects of tooth loss in edentulous people. Br Dent J 1998; 184: 90-93 9. Tallegren A. The continuing reduction of the residual alveolar ridges in complete denture wearers: a mixed longitudinal study covering 25 years. J Prosthet Dent 1972; 27: 120-32 10. Feine S, Carlsson GE. Implant Overdentures The Standard of Care for Edentulous Patients. Quintessence books. Chapter 10 11. Crum R.J, Rooney G.E, Alveolar bone loss in overdentures-5 year study. J Prosthet Dent 1978; 40: 610-613 12. Jacobs R, Schotte A, Van Steenberghe D, Quirynen M, Naert I. Posterior jaw bone resorption in osseointegrated implant-supported overdentures. Clin Oral Impl Res 1992; 3: 63-70 13. Mericske-Stern R. Overdentures with roots or implants for elderly patients: A comparison. J Prosthet Dent 1994; 72: 543-550 14. Redford M, Drury TF, Kingman A, Brown LF. Denture use and the technical quality of dental prostheses among persons 18-74 years of age: United States, 1988-1991 (Special Issue) J Dent Res 1996; 75: 714- 25Image 5 & 6: Placement of implants in a 90 year old patient with a cleft 15. Jennings DE. Treatment of the mandibular compromised ridge: apalate, right: Fabrication of a complete denture with full palatal literature review. J Prosthet Dent 1989; 61(5): 575-9 16. Matras H. A review of surgical procedures designed to increase thecoverage and obturator10 functional height of the resorbed alveolar ridge. Int Dent J 1983; 33(4): 332-8However a panel of experts (The McGill Consensus)17 17. The McGill Consensus Statement on Overdenures. Int J Prosthodontagreed due to overwhelming evidence that the 2-implant 2002; 15(4): 413-414OD should be considered as a first choice standard of 18. Van Steenberghe D, Quirynen M, Calberson L, Demanet M. A prospective evaluation of the fate of 697 consecutive intra-oral fixturescare for the edentulous mandible17. modum Brannemark in the rehabilitation of edentulism. J Head Neck Pathol 1987; 6: 53-58As with any treatment modality, the commitment to after- 19.Albrektsson T, Blomberg S, Brannemark A, Carlsson G. Edentulousness-an oral handicap. Patient reactions to treatment withcare and maintenance is vital if the OD is to be successful. jawbone anchored prostheses. J oral rehabilitation 1980; 14: 503-11The patient must be advised of this and reviewed 20.Attard et al. Long-Term Treatment Outcomes in Edentulous Patientsregularly. As previously mentioned, this may give the with Implant Overdentures: The Toronto Study. Int J Prosthodont 2004;clinician the chance to regularly review the patient and 17: 425-433 21.Visser et al. Implant-Retained Mandibular Overdentures Versusdetect possible pathology which may then be treated in a Conventional Dentures: 10 Years of Care and Aftercare. Int Jtimely fashion. Prosthodont 2006; 19: 271-278 22.Feine S, Carlsson GE. Implant Overdentures The Standard of CareFrom the evidence presented in this paper it can be for Edentulous Patients. Quintessence books. Chapter 13 23.Carlsson GE, Otterland A, Wennstrom A. Patient factors inconcluded that the edentulous patient restored with an appreciation of complete dentures. J Prosthet Dent 1967; 17: 322-28ISMOVD (rather than with a CD with or without PPS) 24.Bergman B, Carlsson GE. Review of 54 complete denture wearers.experiences more satisfaction with their prosthesis, Patients opinions 1 year after treatment. Acta Odontol Scand 1972; 30:improved masticatory ability and nutrition, along with 399-414 25.Awad MA, Locker D, Korner-Bitensky N, Feine JS. Measuring theimprovements in psycho-social aspects of life. However, effect of intra-oral implant rehabilitation on health-related quality of life inprospective randomized studies with longer follow-up a randomized controlled clinical trial. J Dent Res 2000; 79: 1659-1663periods are required. It can also be concluded that 26.Berg E. The influence of some anamnestic, demographic, and clinicalpatients restored with ISMOVDs will experience variables on patient acceptance of new complete dentures. Acta Odontol Scand 1984; 42: 119-127improvements in QOL with regard to oral health-related 27.Pietrokovski J, Harfin J, Mostavoy R, Levy F. Oral findings in elderlyQOL. nursing home residents in selected countries: Quality of and satisfaction with complete dentures. J Prosthet Dent 1995; 73: 132-135 68 TSMJ Vol 8 2007
Reviews: Dentistry 38. Morais J.A., Heydecke G., Pawlick J., Lund J.P., Feine J.S. The28. Naert I, Gizani S, Vuylsteke M, van Steenberghe D. A 5-year effects of Mandibular Two-implant Overdentures on Nutrition in Elderlyprospective randomized clinical trial on the influence of splinted and Edentulous Individuals. J Dent Res 2003; 82(1): 53-58unsplinted oral implants retaining a mandibular overdenture: prosthetic 39. de Jong N, Paw MJ, de Groot LC, de Graaf C, Kok FJ, van Staverenaspects and patient satisfaction. J Oral Rehabil 1999; 26: 195-202 WA. Functional biochemical and nutrient indices in frail elderly people29. Feine JS, de Grandmont P, Boudrais P, Brien N, LaMarche C, Tache are partly affected by dietary supplements but not by exercise. J NutrR et al. Within-subject comparisons of implant-supported mandibular 1999; 129: 20prostheses: the choice of prosthesis. J Dent Res 1994; 73: 1105-11 40. Allen F, McMillan A. Food selection and perceptions of chewing ability30. de Grandmont P, Feine JS, Tache R, Boudrais P, Donohue WB, following provision of implant and conventional prostheses in completeTanguay R et al. Within-subject comparisons of implant-supported denture wearers. Clin Oral Implants Res 2002; 13(3): 320-6mandibular prostheses: psychometric evaluation. J Dent Res 1994; 73: 41. Hamada MO, Garrett NR, Roumananas ED, Kapur KK, Freymiller E,1096-104 Han T. A randomized clinical trial comparing the efficacy of mandibular31. Boerringter E.M. et al. Patient satisfaction with implant-retained implant-supported overdentures and conventional dentures in diabeticmandibular overdentures. A comparison with new complete dentures not patients. Part IV: Comparison of dietary intake. J Prosthet Dent 2001; 85:retained by implants- a multi-centre randomized clinical trial. Br J Oral 53-60and Maxillofacial Surg 1995; 33: 282-288 42. Shinkai RSA, Hatch JP, Rugh JD, Sakai S, Mobley CC, Saunders MJ.32. Humphris GM, Healey T, Howell RA, Cawood J. The psychological Dietary intake in edentulous subjects with good and poor qualityimpact of implant-retained mandibular prosthesis: a cross-sectional complete dentures. J Prosthet Dent 2002; 87: 490-498study. Int J Oral Maxillofac Implants 1995; 10: 437-44 43. Blomberg. Psychological Response. Tissue-integrated prostheses.33. Wismeijer D, Vermeeren IJ, van Waas MA. Patient satisfaction with Osseointegration in Clinical Dentistry. 1985overdentures supported by one-stage TPS implants. Int J Oral Maxillofac 44. Heydecke G, Thomason MJ, Lund J, Feine JS. The impact ofImplants 1992; 7: 51-5 conventional and implant supported prostheses on social and sexual34. Meijer HJ, Raghoeber GM, vant Hof MA, Geertman ME, van Oort activities in edentulous adults. Results from a randomized trial 2 monthsRP. Implant-retained mandibular overdentures compared with complete after treatment. J Dent 2005; 33: 649-657dentures: a 5 year follow-up study of clinical aspects and patient 45. Melas F, Mercenes W, Wright P. Oral Health Impact on Dailysatisfaction. Clin Oral Implants Res 1999; 10: 238-44 Performance in patients with Implant-Stabilized Overdentures and35. Harle TI et al, Patient satisfaction with implant supported prostheses. Patients with Conventional Complete Dentures. J Oral MaxillofacialInt J Prosthodont 1993; 6: 153-62 Implants 2001; 16: 700-71236. Wismeijer D, van Waas MA, Vermeeren JI, Mulder J, Kalk W. Patient 46. Mersel A, Babayof I, Berkey D, Mann J. Variables affecting denturesatisfaction with implant supported mandibular overdentures. A satisfaction in Israeli elderly: A one year follow-up. Gerodontology 1995;comparison of three treatment strategies with ITI-dental implants. Int J 12: 89-94Oral Maxillofac Surg 1997; 26: 263-7 47. Hobkirk, Watson, Searson. Introducing Dental Implants. Churchill37. Raghoeber GM et al. A randomized prospective clinical trial on the Livingstone. Chapter 6effectiveness of three different treatment modalities for patients with 48. Mericske-Stern. Treatment outcomes with implant-supportedlower denture problems. A 10 year follow-up study on patientsatisfaction. Int J Oral Maxillofac Surg 2003; 32: 498-503 overdentures: Clinical considerations. J Prosthet Dent 1998; 79: 66-73 TSMJ Vol 8 2007 69